Physician Visits and Colorectal Cancer Testing Among Medicare Enrollees in North Carolina and South Carolina, 2005

Introduction Many Medicare enrollees do not receive colorectal cancer tests at recommended intervals despite having Medicare screening coverage. Little is known about the physician visits of Medicare enrollees who are untested. Our study objective was to evaluate physician visits of enrollees who lack appropriate testing to identify opportunities to increase colorectal cancer testing. Methods We used North Carolina and South Carolina Medicare data to compare type and frequency of physician visits for Medicare enrollees with and without a colorectal cancer test in 2005. Type of physician visit was defined by the physician specialty as primary care, mixed specialty (more than 1 specialty, 1 of which was primary care), and nonprimary care. We used multivariate modeling to assess the influence of type and frequency of physician visits on colorectal cancer testing. Results Approximately half (46.5%) of enrollees lacked appropriate colorectal cancer testing. Among the untested group, 19.8% had no physician visits in 2005. Enrollees with primary care visits were more likely to be tested than those without a primary care visit. Many enrollees who had primary care visits remained untested. Enrollees with visits to all physician types had a greater likelihood of having colorectal cancer testing. Conclusions We identified 3 categories of Medicare enrollees without appropriate colorectal cancer testing: those with no visits, those who see primary care physicians only, and those with multiple visits to physicians with primary and nonprimary care specialties. Different strategies are needed for each category to increase colorectal cancer testing in the Medicare population.


Introduction
Costs associated with colorectal cancer (CRC) are projected to be between $11.4 and $14 billion in 2020, creating a substantial burden for Medicare enrollees and the Medicare program (1). Illness and death associated with CRC can be reduced through early detection and treatment. Four recommended tests for CRC screening of persons of average risk (2) are covered under Medicare: 1) annual fecal occult blood testing (FOBT); 2) sigmoidoscopy or 3) barium enema every 4 years; or 4) colonoscopy every 10 years. Despite having Medicare coverage for CRC tests, less than half of Medicare enrollees have received CRC tests at the recommended intervals (3).
Much debate about health care reform centered on providing health insurance coverage to uninsured Americans. Although lack of insurance coverage is a leading reason for lack of access to health care, insurance coverage does not ensure access to health care. Aday et al (4) have used the term "realized access" to highlight the importance of factors in addition to insurance coverage and availability of providers that influence consumer access to health care, including the "transactions between patients and providers during the process of care delivery." Physician influence on patients' CRC screening status is well documented. Physician recommendation has been associated with increased likelihood of screening (5,6), and the lack of recommendation has been identified as a barrier (7,8). Having a recent well visit (6), being seen in group practices rather than solo practices (9), and visiting internal medicine physicians rather than other primary care providers (10) have all been linked with increased CRC testing. Understanding physicians' influence on the CRC screening status of Medicare enrollees is, however, complicated by the fragmented care received by most Medicare enrollees. One study showed that most Medicare enrollees see 7 physicians in 4 practices in a given year (9).
The objective of this study was to examine the role of physician visits among Medicare enrollees with and without CRC testing -enrollees who access this preventive service and enrollees with "unrealized access." Our aim was to identify potential opportunities to increase CRC testing in the untested population.

Study population
In

Classification of physician specialty
We identified physician specialty by linking UPINs to the Centers for Medicare and Medicaid Services Physician Specialty table, which contains up to 3 specialties per physician. We classified physician specialties as primary care, mixed specialty, or nonprimary care. We grouped internal medicine, family medicine, general practice, preventive medicine, geriatric medicine, obstetrician/gynecologists, nurse practitioners, and physician assistants under primary care. We classified physicians with more than 1 specialty designation, 1 of which was primary care (for example, internal medicine and cardiology) as mixed specialty. We classified physicians with only nonprimary care specialties as nonprimary care. We limited analysis to visits with medical doctors, doctors of osteopathy, nurse practitioners, physician assistants, certified clinical nurse specialists, and family nurse practitioners, which included 97% of all visits in the applicable study windows.

Calculating physician visits
We were interested in the physician visits during the year before CRC testing. For enrollees with a CRC test in 2005, we examined the 12 months before the date of the CRC test; for noncompliant enrollees who had no CRC test, we used claims for the calendar year 2004 to calculate the frequency of physician visits. We used the term "physician visits" for both doctor and nurse practitioner or physician assistant visits. We excluded visits for critical care and visits to physicians with specialties not involving patient contact (eg, radiology). We excluded visits with physicians whose specialty could not be determined, such as those with bad UPINs or out-of-state physicians (3.5% of visits). Only 1 visit per day was counted for each physician-patient encounter.
We classified enrollees on the basis of specialties of the physicians they visited according to the following 7 categories: 1) only primary care physicians; 2) only nonprimary care physicians; 3) physicians with mixed specialties (1 of which was a primary care specialty); 4) both primary care and mixed-specialty physicians; 5) both primary care and nonprimary care physicians; 6) mixed-specialty and nonprimary care physicians; and 7) primary care, nonprimary care, and mixed-specialty physicians.

Statistical analyses
We present demographic and enrollment characteristics for the 3 groups of enrollees: those tested in 2005 (any test in 2005), those eligible to be tested but not receiving a test in 2005 (not compliant and not tested in 2005), and those who did not need a CRC test (compliant -no test needed). We analyzed physician visits for 2 groups: those who were and were not tested in 2005. Because the data used for these analyses are population-based, we used descriptive rather than inferential statistics.
We used multivariate logistic regression to examine the relative importance of the number and type of physician visits on receipt of a CRC test in 2005. As measures of association between frequency and type of physician visits and receipt of a CRC test, we calculated adjusted odds ratios (ORs) with 95% confidence intervals (95% CIs). We present 3 models: Model 1, among all enrollees, in which we examine the association between number of visits and receipt of CRC testing; Model 2, conducted only for enrollees who had 1 or more physician visits, in which we examine number of visits and physician specialty; and Model 3, among enrollees who had a primary care visit, in which we examine the relationship of number of visits and the type of primary care provider seen. We adjusted all models for enrollee age, race/ethnicity, sex, original reason for eligibility (age or disabling condition), entitlement status (state buy-in or no state buy-in), state of residence, and number of comorbid conditions. Entitlement status refers to eligibility for state Medicaid programs to pay Medicare premiums and serves as a marker for low income.

Results
The Of all Medicare patients who received care from at least 3 different types of physicians (primary care, nonprimary care, and mixed-specialty physicians), only half had a CRC test in 2005 ( Figure 1). Less than one-third of patients who had only primary care, nonprimary care, or mixedspecialty visits had a CRC test.
Medicare patients with obstetrician/gynecologist visits were most likely to be tested in 2005 (47%), followed by patients who had seen physicians with multiple specialties ( Figure 2). Patients who had visits with family or general practice physicians were least likely to be tested (29%   a Physician categories: 1) primary care: internal medicine, family medicine, general practice, preventive medicine, geriatric medicine, obstetrician/gynecologists, nurse practitioners, and physician assistants; 2) mixed specialty: physicians with more than 1 specialty listed, 1 of which was a primary care specialty; ) nonprimary care: physicians with only nonprimary care specialties.
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Discussion
Almost half (47%) of the Medicare population in 2 Southern states was in need of, and did not receive, a CRC test in 2005, a finding consistent with earlier studies showing low CRC test use rates despite Medicare coverage (14)(15)(16). We found that having any physician office visit, increased number of office visits, and visits with primary care physicians were associated with increased CRC test use. We also found that a number of enrollees did not regularly see physicians, and many of those who did have physician contact remained untested.
We identified missed opportunities by all provider types to promote CRC testing. For most specialties, most of their Medicare patients were in need of a CRC test at the time of the visit and did not receive one. The characteristics of the untested group reveal a potentially vulnerable population -those with Medicaid eligibility, who may have disabling conditions and multiple chronic conditions. Most are accessing medical care, but their access to preventive services remains "unrealized." Our findings highlight the gap between coverage and receipt of CRC test and demonstrate the influence of physician visits. We identify 3 categories of Medicare enrollees who are untested: those with no visits, those with primary care visits, and those with visits to multiple types of physicians. This categorization suggests that different strategies may be needed to improve CRC testing in each group.
Previous research has shown preventive or periodic health exams are associated with CRC test use (17). Yet, we found almost 20% of enrollees who needed a CRC test had no physician contact during the year of observation. In 2011, Medicare will allow 1 annual wellness visit during which counseling on CRC screening could occur. However, prior experience indicates that coverage of a wellness visit by itself will not assure Medicare enrollees use it -in 2006 and 2007, only 3% of enrollees used the "Welcome to Medicare" visit (18). Outreach to new Medicare enrollees, and "in-reach" to recall patients who have not recently been seen, may improve CRC testing rates (19).
As a stand-alone strategy, encouraging enrollees to visit primary care physicians may not result in substantial improvements in CRC testing at the population level (20). In our cohort, many enrollees remained untested regardless of the frequency of visits. Our findings are consistent with earlier studies reporting that contact with physicians is not sufficient to ensure that CRC testing will be com-pleted (5,15,21,22). Greater understanding of tools and systems is needed to support physicians in the promotion of CRC testing. Factors identified as barriers to physicians offering CRC testing include the limited amount of time for a patient visit, competing priorities, and lack of office systems to facilitate screening (23)(24)(25). Increased CRC screening referrals have been documented through the use of simple tools such as chart stickers and reminders (26). A toolbox containing sample policies, reminder systems, and communication approaches is available from the National Colorectal Cancer Roundtable to assist physicians in increasing CRC testing (www.nccrt.org).
Physician attitudes toward cancer screening may vary by specialty. The higher rate of CRC testing we found among enrollees with an obstetrician/gynecologist visit is consistent with findings from an earlier study showing significantly higher rates of mammography referral for patients treated by obstetrician/gynecologists compared with other primary care physicians (27).
Although strategies to improve CRC testing typically target primary care physicians (28,29), we found that a combination of primary care and specialist visits was associated with increased CRC testing. A recent study reported that specialists spend a substantial portion of their time providing routine care and preventive services to their patients (30). Electronic health records (EHRs) offer potential for improving CRC testing among all physicians, including specialists, by alerting physicians to patients' test status. EHRs could identify and recall patients for screening, remind office staff to counsel patients about screening, and monitor screening compliance. An EHR system with the ability to exchange information across settings may be the only feasible way to manage the multiplicity of communication that needs to occur between the many physicians providing care to Medicare enrollees.

Study limitations and strengths
CRC testing rates are known to vary by geographic region (3,31,32). Different patterns may be observed in other locations. Current US Preventive Services Task Force recommendations on CRC screening recommend against routine screening of people aged 76 to 85 (33). We included this age group in this study because we were targeting unscreened Medicare enrollees. CRC testing for some enrollees in this age group may not be appropriate.
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
The strong associations observed between number and type of physician visits and receipt of CRC testing are open to several interpretations. They may represent causal relationships, meaning increasing the number and type of physician visits would raise CRC test rates. However, it is also possible the associations are driven by medical conditions that cause patients to visit doctors more frequently or other characteristics that may independently lead to being tested for CRC.
Medicare data provide the opportunity to study a large population, examining care received from multiple providers to accurately measure CRC test status (12,13). They are not, however, without limitations. Tests conducted before patients enter Medicare are not available. Younger enrollees who had endoscopy before entering Medicare may not be due for another test. Additionally, we had access to claims from an 8-year window (1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005).
Medicare enrollees who had colonoscopy during 1996 through 1997 would be incorrectly classified in our data as untested. Medicare did not cover screening for CRC during that time period, and diagnostic test use was low. The effect of these data limitations is minimal, as our population-based rates compare favorably with rates from national surveys (3,34).

Conclusions
Increased CRC screening would reduce CRC death, but much work remains to be done to realize that benefit. Working with the Medicare population to increase "realized" access for those with insurance may inform approaches to access as we move toward health insurance reform.     Abbreviations: OR, odds ratio; CI, confidence interval; NA, not applicable because variable not included in the model. a For Model 1, the association between number of visits and receipt of colorectal cancer testing was examined among all enrollees. b For Model 2, the association between number of visits and physician specialty were examined only for enrollees who had 1 or more physician visits. c For Model , the association between number of visits and the type of primary care provider seen was examined for enrollees who had primary care visits. d State buy-in indicates the enrollee is eligible for Medicaid to "buy" Medicare coverage. e Classified using Charlson index (11) modified for use with claims data. Categories indicate the number of Charlson conditions identified. Unknown indicates insufficient claims available to assess comorbidity. f Physician categories: 1) primary care: internal medicine, family medicine, general practice, preventive medicine, geriatric medicine, obstetrians/gynecologists, nurse practitioners and physician assistants; 2) mixed specialty: physicians with more than 1 specialty listed, 1 of which was a primary care specialty; ) nonprimary care: physicians with only nonprimary care specialties.